State Consumer Disputes Redressal Commission
Sanjay Tata vs Sbi Life Insurance Co. Ltd. & Ors. on 11 January, 2022
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miHkksDrk fookn Áfrrks"k vk;ksx] iaMjh] jk;iqj ifjokn izdj.k Øekad % CC/2019/23 lafLFkr fnukad&02-05-2019 lat; VkVk vkRet izHkqnkl VkVk irk&12@583] ia jfo'kadj LVsfM;e jksM] jk;iqj] ftyk jk;iqj ¼N-x-½ --------------------------------------------------------------------ifjoknh fo:) 1- SBI Life Insurance Company Limited , Head Claims, Central Processing Centre, 8th Leval, Seawoods Grand Central, Central Tower -2 , Plot No. R-1 , Sector-40, Seawoods , Nerul Node ,Navi Mumbai-400706 2- SBI Life Insurance Company Limited 4 th Floor , Pujari Chambers , Pachpedi Naka, Raipur (Chhattisgarh)-492001 3- State Bank of India, Through : Branch Manager, Ravishankar University, Raipur Branch, R.S.University, Raipur, Dist-Raipur (Chhattisgarh)-492002 ----------------------------fo:) i{kdkjx.k le{k% ekuuh; U;k;ewfrZ Jh lh- ch- cktis;h] v/;{k ekuuh;k Jhefr :fp xks;y] lnL;k ekuuh; Jh xksiky panz 'khy] lnL;
ekuuh; Jh izeksn dqekj oekZ] lnL;
i{kdkjksa ds vf/koDrk Jh vkj- ds- Hkkoukuh] vf/koDrk okLrs ifjoknhA Jh ujsna z feJk vf/koDrk] okLrs fo:) i{kdkj Øekad&1 vkSj 2- Jh ,u- ds- JhokLro] vf/koDrk okLrs fo:) i{kdkj Øekad&3- vkns'k fnukad% 11@01@2022 }kjk%&ekuuh;k Jhefr :fp xks;y] lnL;k Ikfjoknh us ;g ifjokn /kkjk&17 miHkksDrk laj{k.k vf/kfu;e] 1986 ds varxZr fo:) i{kdkjx.k ls fuEukuqlkj vuqrks"k fnyk;s tkus gsrq izLrqr fd;k gS%& // 2 // **1- fo:) i{kdkj dzekad&1 ,oa 2 dks funsZf'kr fd;k tkos fd os fo:) i{kdkj dzekad&3 dks leLr cdk;k jkf'k&18]79]660@&¼vV~Bkjg yk[k mU;klh gtkj N% lkS lkB :Ik;s½ dk Hkqxrku djsa ,oa ifjoknh dks izkIr gksus okys leLr ykHk iznku djsa A 2- ifjoknh dks lsok esa fuEurk] ekufld ijs'kkuh ,oa vuqfpr O;kikj ds ,ot esa 5]00]000@&¼ikap yk[k :Ik;s½ dk gtkZuk fnyok;k tkos A 3- okn&O;; ,oa vU; vuqrks"k tks Hkh ekuuh; vk;ksx tks mfpr le>s] fnyok;k tkos A 02- ifjoknh dk ifjokn laf{kIr esa bl izdkj gS ifjoknh Lo- laxhrk /kkesfy;k dk HkkbZ gS ,oa ifjoknh dh cgu ds }kjk yh xbZ ikWfylh esa ukWfeuh FkkA ifjoknh dh cgu ds }kjk fo:) i{kdkj Øekad&3 ls yksu fy;k x;k Fkk ftldk yksu vdkmaV uacj&37240912146 rFkk ;w- vkbZ- ,u- uacj 111NO78V03 gSA ifjoknh dh cgu dks 15]972@&¼ianzg gtkj ukS lkS cgRrj :i;s½ izfrekg dh fd'rksa dk Hkqxrku djuk FkkA ifjoknh dh cgu dks dqy yksu jkf'k 18]00]000@&¼vV~Bkjg yk[k :i;s½ Lohd`r fd;k x;k Fkk ftldk 180 ekg esa Hkqxrku djuk FkkA dqy chfer jkf'k 18]79]860@&¼vV~Bkjg yk[k mU;klh gtkj vkB lkS lkB :i;s½ FkhA ifjoknh dh cgu ds yksu vdkmaV ds lac/a k esa fo:) i{kdkj Øekad&3 ds }kjk fo:) i{kdkj Øekad&1 ,oa 2 ls ,d ikWfylh Øekad&70000018310 fnukad&01-11-2017 dks yh xbZ Fkh rFkk fo:) i{kdkj Øekad&1 ,oa 2 ds }kjk lfVZfQdsV vkWQ ba';ksjsal tkjh fd;k x;k FkkA ifjoknh mDr yksu vdkmaV esa ukWfeuh FkkA fo:) i{kdkj Øekad&1 ,oa 2 ds }kjk tkjh ikWfylh esa ;fn ikWfylh /kkjd dh e`R;q gks tkrh gS rks ukWfeuh chek ikWfylh dk leLr ykHk ikus dk vf/kdkjh gksxkA ifjoknh dh cgu Jhefr laxhrk /kkesfy;k ds }kjk izFke // 3 // izhfe;e dh jkf'k 15]972@&¼ianzg gtkj ukS lkS cgRrj :i;s½ iVk;k x;k FkkA fnukad&11-05-2018 LokLF; [kjkc gksus dh otg ls ifjoknh dh cgu Jhefr laxhrk /kkesfy;k dh e`R;q Hkhejko vacsMdj vLirky jk;iqj esa gks xbZ ftldk e`R;q izek.k&i= fnukad&19-05-2018 dks tkjh fd;k x;kA ifjoknh ds }kjk fo:) i{kdkjx.k dks mijksDr laca/k esa lwpuk nh xbZ rFkk leLr nLrkost iznku fd;s x;sA fo:) i{kdkjx.k ds }kjk fnukad&02-01-2019 dks ifjoknh ds nkos dks bl vk/kkj ij fujLr dj fn;k x;k fd "However as per the treatment papers dated October 2017 available with us , Late Sangeeta Dhameliya was operated for Tumor and Surffering from Heart Disease , Diabetes Mellitus and was taking treatment for the same prior to the date of commencement of the policy." Ifjoknh] fo:) i{kdkjx.k dk mijksDr i= ikdj vokd~ jg x;k D;ksfa d chfer O;fDr ds }kjk dksbZ Hkh xyr tkudkjh ugha nh xbZ FkhA fo:) i{kdkj Øekad&1 vkSj 2 ds }kjk fnukad&02-01-2019 dks fo:) i{kdkj Øekad&3 dks i= fy[kdj ifjoknh ds nkos dks fujLr fd;s tkus dh lwpuk nh xbZA ifjoknh ds }kjk dksbZ Hkh ,slk dk;Z ugha fd;k x;k Fkk tks chek ikWfylh dh 'krksZa dk mYya?ku gksA fo:) i{kdkjx.k ds }kjk ifjoknh ds oS/k nkos dks vuqfpr vk/kkjksa ij fujLr fd;k x;k gSA ifjoknh ds }kjk vius vf/koDrk ds ekQZr ls fnukad&27-02-2019 dks uksfVl Hksth xbZ ftlesa ;g fuosnu fd;k x;k fd fo:) i{kdkj Øekad&1 vkSj 2 dks funsZf'kr fd;k tkos fd fo:) i{kdkj Øekad&3 dks leLr cdk;k jkf'k dk Hkqxrku djsa vkSj tks {kfriwfrZ ifjoknh dks izkIr gksuh gS mls iznku fd;k tkosA fo:) i{kdkj Øekad&1 ,oa 2 ds }kjk fnukad&07-03-2019 dks ifjoknh dh vksj ls Hksth xbZ uksfVl dk vlR; vk/kkjksa // 4 // ij tokc izsf"kr fd;k x;kA fo:) i{kdkjx.kksa ds }kjk ifjoknh ds oS/k nkos tks fd 18]79]860@&¼vV~Bkjg yk[k mU;klh gtkj vkB lkS lkB :i;s½ dk Hkqxrku ugha fd;k tk jgk gS vkSj ifjoknh dks feyus okys ykHkksa ls oafpr fd;k tk jgk gSA fo:) i{kdkjx.kksa dk mijksDr d`R; Li"V :i ls lsok esa fuEurk dh Js.kh esa vkrk gS ftlds dkj.k ifjoknh dks ;g ifjokn ykus dh vko';drk iM+h gSA vr% ifjokn&i= esa of.kZr vuqlkj vuqrks"k fnykbZ tkosA 03- fo:) i{kdkjx.k Øekad&1 vkSj 2 dh vksj ls fyf[kr dFku izLrqr djrs gq, ;g vfHkopu fd;k x;k gS fd e`rd Jhefr laxhrk /kkesfy;k us _.k dh lqj{kk gsrq j{kk lewg chek ;kstuk ds rgr ekLVj ikWfylh uacj&70000018310 izkIr fd;k Fkk A mDr ikWfylh ds fy, iziksty QkeZ fnukad&01-11-2017 dks Hkjk x;k Fkk A mDr ikWfylh esa tksf[ke fnukad& 16-11-2017 ls izkjaHk gqvk Fkk A ifjoknh dh cgu us iwoZ chekfj;ksa dks fNikrs gq, chek ikWfylh izkIr dh Fkh ] tcfd chek lafonk ije ln~Hkkouk ds fl)kar ij vk/kkfjr gksrh gS A chekdrkZ us chek ds fu;e ,oa 'krksZa dk mYya?ku fd;k gS A ftlds dkj.k fo:) i{kdkj Øekad&1 vkSj 2 ds }kjk ifjoknh dk nkok izi= fujLr fd;k x;k gS A chekFkhZ us chek ikWfylh fnukad&16-11-2017 dks yh Fkh rFkk e`R;q fnukad&11-05-2018 dks gqbZ Fkh A ikWfylh ysus ds 5 ekg 25 fnu esa gh chekFkhZ dh e`R;q gks xbZ Fkh A bl e`R;q nkok dh tkap ds fy, vUos"kd fu;qDr fd;k x;k A vUos"kd us tkap ds nkSjku ik;k fd chekFkhZ Mk;fcfVd II ,oa g`n; laca/kh chekjh ls xzflr gS rFkk chekFkhZ dk iwoZ esa V~;wej dk vkWijs'ku Hkh gks pqdk gS A vUos"k.k fjiksVZ dh izfr izn'kZ D-4 layXu gS A izLrkod chekFkhZ us // 5 // izLrko&i= esa LokLF; lacfa /kr iwNs x;s iz'uksa ds lkeus No dj fn;k Fkk A chek/kkjd }kjk izLrko i= dh dafMdk&5 dh midafMdk (I ls IX rd ) esa Lo;a dks fdlh Hkh chekjh ls xzflr gksuk ugha crk;k gS ] tcfd chekFkhZ fnukad&10- 10-2017 ds iwoZ ls Mk;fcfVd II fiNys 8 lky ls ,oa g`n; laca/kh chekjh ls xzflr Fkh A bl izdkj NyiwoZd /kks[ks ls ikWfylh izkIr fd;k gS A chek/kkjd dh e`R;q chek ikWfylh ysus ds iwoZ fo|eku chekjh ds dkj.k gqbZ gS A lq;'k gkWfLiVy dh fMLpktZ ,oa bejtsl a h ,lslesaV fnukad&10-10-2017 ds vuqlkj chekFkhZ ¼fiNys vkB lkyksa ls ½ DM II rFkk GERD (Gastro esophageal reflux disease) ls xzflr Fkk rFkk chekFkhZ dks Cardio Vaseular Surgery dh lykg nh xbZ Fkh A fMLpktZ lejh esa DMC ¼nks o"kZ iwoZ½ ,oa V~;qej vkWijs'ku 2011 esa gqvk gS ] fy[kk Fkk A chekFkhZ dh fpfdRldh; vodk'k dh lwph Hkh layXu dh xbZ gS ] ftlls irk pyrk gS fd chekFkhZ fnukad&10-08-2017 ls 06-09-2017 rd 12-09- 2017 ls 27-09-2017 rd fnukad&28-09-2017 ls 28-10-2017 rd ,oa fnukad&17- 04-2018 ls 26-04-2018 rd yxkrkj dbZ ckj fpfdRldh; vodk'k yh gS ] ftlls Li"V gS fd chekFkhZ chek ysus iwoZ ls gh chekj py jgh Fkh ] fdarq chekFkhZ }kjk izLrko&i= esa chekjh lacfa /kr rkfRod rF; Nqik;s x;s Fks A chekFkhZ iwoZ ls gh Mk;fcfVd II rFkk g`n; laca/kh ¼chek ikWfylh ysus ds iwoZ½ chekjh ls ihfM+r Fkh vkSj blh iwoZorhZ chekfj;ksa ds dkj.k gh chekFkhZ dh e`R;q gqbZ gS A chek daiuh }kjk ikWfylh ds fu;e ,oa 'krksZa ds v/khu gh nkok ns; uk gksus ls nkok vLohdkj fd;k x;k gs ] ftldh lwpuk ifjoknh dks fnukad&02-01-2019 nkok fujLrh i= }kjk nh xbZ gS rFkk ikWfylh ds fu;e o 'krksZa ds v/khu fizfe;e jkf'k :-13536 @&¼rsjg gtkj ikap lkS NRrhl :i;s½ ifjoknh ds vkbZ-
// 6 // Mh-ch-vkbZ cSad [kkrk Øekad&1103104000005105 esa fnukad&31-12-2018 dks tek dj nh xbZ gS A bl izdkj fo:) i{kdkj Øekad& 1 ,oa 2 us chek ikWfylh ds fu;e o 'krksZa ds v/khu dk;Z djrs gq, chek nkok ns; uk gksus ij fujLr dj lsok esa dksbZ deh ugha dh gS A vr% ifjoknh dk ifjokn lO;; fujLr fd;k tkos A 04 fo:) i{kdkjx.k Øekad&3 dh vksj ls fyf[kr dFku izLrqr djrs gq, ;g vfHkopu fd;k x;k gS fd ifjoknh ikWfylh dh 'krksZa ds vuqlkj gh mDr ikWfylh ds varxZr fo:) i{k Øekad&1 vkSj 2 ls fgrykHk izkIr djus dk vf/kdkjh gSA fo:) i{kdkj Øekad&3 ds }kjk fdlh Hkh izdkj dk dksbZ nkok fujLrhdj.k dk vkns'k tkjh ugha fd;k x;k gSA fo:) i{kdkj Øekad&3 us ifjoknh dh cgu Jhefr laxhrk /kkesfy;k dks x`g _.k iznku fd;k Fkk vkSj mDr x`g _.k dks iznku djrs le; ifjoknh ds funsZ'k ij ,d chek ikWfylh fo:) i{kdkj Øekad&1 vkSj 2 ls Ø; djus gsrq _.kh ds [kkrs ls izhfe;e dh jkf'k ukesa dj fo:) i{kdkj Øekad&1 vkSj 2 dks Hkqxrku dh Fkh ftlds i'pkr~ fo:) i{kdkj Øekad&1 vkSj 2 us _.kh ds izLrko i= esa fd;s x;s dFku ij fo'okl dj iz'ukafdr chek ikWfylh tkjh dh Fkh rFkk _.kh dh e`R;q ds i'pkr~ ifjoknh }kjk fo:) i{kdkj Øekad&1 vkSj 2 ds le{k e`R;q nkok izLrqr djus ij fo:) i{kdkj Øekad&1 vkSj 2 }kjk ifjoknh ds nkos dks ;g dgrs gq, fd _.kh chek/kkjd }kjk chek ikWfylh Ø; djrs le; vius LokLF; ls lacfa /kr egRoiw.kZ rF;ksa dks chek izLrko&i= esa fNik;k x;k Fkk ftlds dkj.k fo:) i{kdkj Øekad&1 vkSj 2 }kjk /kkjk&45 chek vf/kfu;e ds izko/kkuksa ds // 7 // rgr ifjoknh dk nkok fujLr dj fn;k x;kA bl izdkj fo:) i{k Øekad&3 ds }kjk ifjoknh ;k _.kh@chek/kkjd ds lkFk fdlh Hkh izdkj dh dksbZ lsok esa fuEurk ;k deh ugha dh xbZ gSA fo:) i{kdkj Øekad&3 ,d cSafdax laLFkk gS ftldk dk;Z cSafdax djuk gSA fo:) i{kdkj Øekad&1 vkSj 2 chek daiuh gS blfy, bl iwjs izdj.k esa ;fn ifjoknh dks fdlh Hkh izdkj dk dksbZ nkok ns; gS rks mldh iw.kZ :i ls ftEesnkjh fo:) i{kdkj Øekad&1 vkSj 2 dh gSA fo:) i{kdkj Øekad&3 dk ;g dFku gS fd _.kh chek /kkjd }kjk tks fo:) i{kdkj Øekad&3 ls _.k izkIr fd;k x;k gS mlds _.k ds Hkqxrku dh izFke ftEesnkjh mlds fof/kd okfjl gksus ls ifjoknh dh gSA ;fn fdlh Hkh dkj.k ls fo:) i{kdkj Øekad&1 vkSj 2 }kjk ifjoknh ds }kjk izLrqr chek nkos dk Hkqxrku ugha fd;k tkrk gS rks ,slh fLFkfr esa ifjoknh] fo:) i{kdkj Øekad&3 dks _.kh }kjk fy;s x;s _.k ds Hkqxrku ds fy, ftEesnkj gS rFkk ;fn bl izdj.k esa ekuuh; U;k;ky; }kjk ifjoknh dk nkok Lohdkj fd;k tkrk gS rks ,slh fLFkfr esa fo:) i{kdkj Øekad&1 vkSj 2 ls ifjoknh dks izkIr gksus okyh chek dh jde dks _.kh ds yafcr _.k [kkrs lek;ksftr djus gsrq vknsf'kr fd;k tkosA _.kh chek/kkjd ,oa fo:) i{kdkj Øekad&1 vkSj 2 ds chp gqbZ chek lafonk ds rgr~ chek nkok Hkqxrku djus dh ftEesnkjh pwafd fo:) i{kdkj Øekad&1 vkSj 2 dh gS rFkk fo:) i{kdkj Øekad&3 }kjk bl izdj.k esa fdlh Hkh izdkj dh dksbZ lsok esa fuEurk ;k deh ;k vuqfpr O;kikj O;ogkj ifjoknh ds lkFk ugha fd;k x;k gSA ifjoknh }kjk bl izdj.k eas vuko';d :i ls bl fo:) i{kdkj Øekad&3 dks i{kdkj cuk;k x;k gS ftlds dkj.k ifjoknh dk ;g ifjokn fo:) i{kdkj Øekad&3 ds fo:) lO;; fujLr fd;s tkus ;ksX; gSA // 8 // fo:) i{kdkj Øekad&3 dks ifjoknh ls miHkksDrk laj{k.k vf/kfu;e dh /kkjk&26 ds izko/kkuksa ds rgr~ O;FkZ dk ifjokn izLrqr dj fo:) i{kdkj Øekad&3 dks rax ,oa ijs'kku djus gsrq 10]000@&¼nl gtkj :i;s½ ,oa 10]000@&¼nl gtkj :i;s½ okn O;; fnyk;k tkos A 05 ifjoknh dh vksj ls vius i{k leFkZu eas Lo;a dk "kiFk&i= rFkk lwph vuqlkj nLrkost izLrqr fd;k x;k gSA 06 fo:) i{kdkj Øekad&1 vkSj 2 dh vksj ls vius i{k leFkZu esa uhye flag ,- Ogh- Ikh- yhxy dk "kiFk&i= ,oa lwph vuqlkj nLrkost izLrqr fd;k x;k gSA 07 fo:) i{kdkj Øekad&3 dh vksj ls vius i{k leFkZu esa ljnkj flag /kqoZs "kk[kk izca/kd dk "kiFk&i= izLrqr fd;k x;k gSA 08- ifjoknh dh vksj ls milatkr gksus okys vf/koDrk Jh vkj- ds- Hkkoukuh }kjk ;g rdZ fd;k x;k fd ifjoknh Lo- laxhrk /kkesfy;k dk HkkbZ gS ,oa ifjoknh dh cgu ds }kjk yh xbZ ikWfylh esa ukWfeuh FkkA ifjoknh dh cgu ds }kjk fo:) i{kdkj Øekad&3 ls yksu fy;k x;k FkkA ifjoknh dh cgu dks 15]972@&¼ianzg gtkj ukS lkS cgRrj :i;s½ izfrekg dh fd'rksa dk Hkqxrku djuk FkkA ifjoknh dh cgu dks dqy yksu jkf'k 18]00]000@&¼vV~Bkjg yk[k :i;s½ Lohd`r fd;k x;k Fkk ftldk 180 ekg esa Hkqxrku djuk FkkA dqy chfer jkf'k&18]79]860@&¼vV~Bkjg yk[k mU;klh gtkj vkB lkS lkB :i;s½ FkhA ifjoknh mDr yksu vdkmaV esa ukWfeuh FkkA fo:) i{kdkj Øekad&1 ,oa 2 ds // 9 // }kjk tkjh ikWfylh ds izHkko"khy jgrs ;fn ikWfylh /kkjd dh e`R;q gks tkrh gS rks ukWfeuh chek ikWfylh dk leLr ykHk ikus dk vf/kdkjh gksxkA ifjoknh dh cgu Jhefr laxhrk /kkesfy;k ds }kjk izFke izhfe;e dh jkf'k&15]972@&¼ianzg gtkj ukS lkS cgRrj :i;s½ iVk;k x;k FkkA fnukad&11-05-2018 LokLF; [kjkc gksus dh otg ls ifjoknh dh cgu Jhefr laxhrk /kkesfy;k dh e`R;q Hkhejko vacM s dj vLirky jk;iqj esa gks xbZA ifjoknh ds }kjk fo:) i{kdkjx.k dks mijksDr lac/a k esa lwpuk nh xbZ rFkk leLr nLrkost iznku fd;s x;sA fo:) i{kdkjx.k ds }kjk fnukad&02-01-2019 dks ifjoknh ds nkos dks fujLr fd;k x;k ftldk dkj.k chek daiuh us chekdrkZ dh esfMdy mipkj iphZ ds vuqlkj izLrko&i= Hkjus ls iwoZ gh Heart Disease ¼g`n; laca/kh chekjh½] Diabetes Mellitus Disease ,oa V~;wej dk vkWijs'ku djkus dk mYys[k Fkk ftls chekdrkZ ds }kjk iziksty QkeZ esa ugha crk;k x;kA chek/kkjd dh e`R;q chek ikWfylh ysus ds iwoZ fo|eku chekjh ds dkj.k gh gqbZ gSA tcfd ifjoknh ds }kjk dksbZ Hkh ,slk dk;Z ugha fd;k x;k Fkk tks chek ikWfylh dh 'krksZa dk mYya?ku gksA fo:) i{kdkjx.k ds }kjk ifjoknh ds oS/k nkos dks vuqfpr vk/kkjksa ij fujLr fd;k x;k gSA QyLo:Ik ifjoknh dk ifjokn Lohdkj fd;k tkos vkSj ifjoknh dks ifjokn&i= esa of.kZr vuqlkj vuqrks"k iznku dh tkosA 09- fo:) i{kdkj Øekad&1 vkSj 2 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh ujsanz feJk dk ;g rdZ gS fd e`frdk Jhefr laxhrk /kkesfy;k us _.k dh lqj{kk gsrq j{kk lewg chek ;kstuk ds rgr ekLVj ikWfylh uacj&70000018310 izkIr dh FkhA mDr ikWfylh ds fy, iziksty QkeZ // 10 // fnukad&01-11-2017 dks Hkjk x;k FkkA mDr ikWfylh esa tksf[ke fnukad&16-11- 2017 ls izkjaHk gqvk FkkA ifjoknh dh cgu us iwoZ chekfj;ksa dks fNikrs gq, chek ikWfylh izkIr dh Fkh] tcfd chek lafonk ije ln~Hkkouk ds fl)kar ij vk/kkfjr gksrh gSA chekdrkZ us chek ds fu;e ,oa 'krksZa dk mYya?ku fd;k gSA ftlds dkj.k fo:) i{kdkj Øekad&1 vkSj 2 ds }kjk ifjoknh dk nkok izi= fujLr fd;k x;k gSA izLrkod chekFkhZ us izLrko&i= esa LokLF; lacaf/kr iwNs x;s iz'uksa ds lkeus mRrj No dj fn;k FkkA chek/kkjd }kjk izLrko i= dh dafMdk&5 dh midafMdk ( I ls IX rd ) esa Loa; dks fdlh Hkh chekjh ls xzflr gksuk ugha crk;k gS] tcfd chekFkhZ fnukad&10-10-2017 ds iwoZ ls Mk;fcfVd II fiNys 8 lky ls ,oa g`n; laca/kh chekjh ls xzflr FkhA bl izdkj NyiwoZd /kks[ks ls ikWfylh izkIr fd;k gSA chek/kkjd dh e`R;q chek ikWfylh gksus ds iwoZ fo|eku chekjh ds dkj.k gqbZ gSA lq;'k gkWfLiVy dh fMLpktZ ,oa bejtsalh ,lslesVa fnukad&10-10-2017 ds vuqlkj chekFkhZ ¼fiNys vkB lkyksa ls½ DM II rFkk GERD (Gastro esophageal reflux disease) ls xzflr Fkk rFkk chekFkhZ dks Cardio Vaseular Surgery dh lykg nh xbZ FkhA fMLpktZ lejh esa DMC ¼nks o"kZ iwoZ½ ,oa V~;qej vkWijs'ku 2011 esa gqvk gS] fy[kk FkkA chekFkhZ iwoZ ls gh Mk;fcfVd II rFkk g`n; laca/kh ¼chek ikWfylh ysus ds½ iwoZ chekjh ls ihfM+r Fkh vkSj blh iwoZorhZ chekfj;ksa ds dkj.k gh chekFkhZ dh e`R;q gqbZ gSA chek daiuh }kjk ikWfylh ds fu;e ,oa 'krksZa ds v/khu gh nkok ns; uk gksus ls nkok vLohdkj fd;k x;k gS ftldh lwpuk ifjoknh dks fnukad&02-01-2019 nkok fujLrh i= }kjk nh xbZ gS rFkk ikWfylh ds fu;e o 'krksZa ds v/khu fizfe;e jkf'k :-13536@&¼rsjg gtkj ikap lkS NRrhl :i;s½ ifjoknh ds vkbZ-Mh-ch-vkbZ cSad [kkrk // 11 // Øekad&1103104000005105 esa fnukad&31-12-2018 dks tek dj nh xbZ gSA bl izdkj fo:) i{kdkj Øekad&1 ,oa 2 us chek ikWfylh ds fu;e o 'krksZa ds v/khu dk;Z djrs gq, chek nkok ns; uk gksus ij fujLr dj lsok esa dksbZ deh ugha dh gSA vr% ifjoknh dk ifjokn lO;; fujLr fd;k tkosA 10- fo:) i{kdkj Øekad&3 dh vksj ls milatkr gksus okys fo}ku vf/koDrk Jh ,u- ds- JhokLro }kjk ;g rdZ izLrqr fd;k x;k gS fd _.kh chek/kkjd ,oa fo:) i{kdkj Øekad&1 vkSj 2 ds chp gqbZ chek lafonk ds rgr~ chek nkok Hkqxrku djus dh ftEesnkjh pwfa d fo:) i{kdkj Øekad&1 vkSj 2 dh gS rFkk fo:) i{kdkj Øekad&3 }kjk bl izdj.k esa fdlh Hkh izdkj dh dksbZ lsok esa fuEurk ;k deh ;k vuqfpr O;kikj&O;ogkj ifjoknh ds lkFk ugha fd;k x;k gSA ifjoknh }kjk bl izdj.k eas vuko';d :i ls bl fo:) i{kdkj Øekad&3 dks i{kdkj cuk;k x;k gS ftlds dkj.k ifjoknh dk ;g ifjokn fo:) i{kdkj Øekad&3 ds fo:) lO;; fujLr fd;s tkus ;ksX; gSA 11- geus mHk;&i{k ds fo}ku vfHkHkk'kdx.k dk rdZ Jo.k fd;k vkSj vfHkys[k dk voyksdu fd;kA 12- izdj.k ds fujkdj.k gsrq fuEu fopkj.kh; iz'u mn~Hkwr gksrs gSa %& ¼1 ½ D;k fo:) i{kdkjx.k }kjk lsok esa dksbZ deh dh xbZ gS\ ¼2 ½ D;k ifjoknh okafNr vuqrks"k ikus dk vf/kdkjh gS\ ;fn gka rks fdl lhek rda\ // 12 // 13- ifjoknh ds fo}ku vf/koDrk }kjk ;g rdZ fd;k x;k fd ifjoknh dh cgu Jhefr laxhrk /kkesfy;k }kjk yksu dh lqj{kk gsrq _.k j{kk xqzi ba';ksjsal Ldhe ds varxZr ikWfylh yh xbZ FkhA ;g ikWfylh fnukad&16-11-2017 ls 16-11-2032 rd izHkko'kkyh FkhA ifjoknh dh cgu Jhefr laxhrk /kkesfy;k dh e`R;q fnukad&11-05-2018 dks gks xbZ FkhA ifjoknh mDr yksu ,dkmaV dk ukWfeuh FkkA ifjoknh ds }kjk fo:) i{kdkjx.k dks e`R;q dh lwpuk rFkk lacfa /kr lHkh nLrkost iznku fd;s FksA fo:) i{kdkjx.k }kjk fnukad&02-01-2019 dks ifjoknh dk nkok ;g dgrs gq, fd fujLr dj fn;k x;k fd ifjoknh iwoZorhZ chekjh ls ihfM+r Fkh tks fd chek ikWfylh dh fu;e ,oa 'krksZa dk mYya?ku gSA fo:) i{kdkjx.k }kjk ifjoknh ds oS/k nkos dks vuqfpr vk/kkj ij fujLr fd;k x;k gSA ifjoknh }kjk izLrqr fpfdRlh; nLrkost esa fdlh Hkh iwo ZorhZ chekjh dk mYys[k ugha gSA e`frdk Jhefr laxhrk /kkesfy;k ds }kjk iziksty QkeZ esa dsoy gLrk{kj fd;s x;s FksA lai.w kZ iziksty QkeZ fo:) i{kdkjx.k }kjk gh Hkjk x;k FkkA e`frdk ds }kjk dHkh Hkh chek daiuh dks dksbZ Hkh xyr tkudkjh ugha nh xbZ FkhA ifjoknh }kjk izLrqr C-11 lq;'k gkWfLiVy dh fMLpktZ lejh gSA mDr lejh esa ikLV esfMdy fgLVªh ds lkeus No. H/O DM , HTN , COPD, CAD fy[kk gSA blls Li"V gS fd ifjokfnuh dks iwoZ esa dksbZ Hkh ,slh chekjh ugha FkhA fo:) i{kdkj }kjk izLrqr OP-04 ba';ksjsal vUos{k.k ,oa losZ;j dh fjiksVZ gSA mDr fjiksVZ esa vUos{kd }kjk fdlh Hkh ifjokj ds lnL;] fe=ksa ,oa vU; O;fDr ls dksbZ Hkh LVsVesaV ugha fy;k x;k Fkk ] uk gh fo:) i{kdkjx.k }kjk izLrqr vUos"k.k fjiksVZ ds leFkZu esa vUos"kd dk 'kiFk&i= Hkh izLrqr fd;k x;k gSA ifjoknh us iksLVekVZe fjiksVZ rFkk vfrfjDr 'kiFk&i= izLrqr fd;k x;k gSA // 13 // mDr iksLVekVZe fjiksVZ esa e`R;q dk dkj.k dkfMZ;ks jsfLisjsVjh QSyqcj crk;k x;k gSA fnukad&11-05-2018 dks Jhefr laxhrk /kkesfy;k dh vpkud rfc;r [kjkc gks tkus dh otg ls mUgas Hkhejko vEcsMdj gkWfLiVy ys tk;k x;k tgka mudh e`R;q gks xbZA e`frdk Jhefr laxhrk /kkesfy;k iwoZ esa fdlh Hkh g`n; laca/kh jksx ls xzflr ugha Fkh A fo:) i{kdkjx.k }kjk xyr vk/kkjksa ij ifjoknh ds oS/k nkos dks fujLr fd;k x;k gS ] tks vuqfpr O;kikj dh Js.kh esa vkrk gSA ifjoknh ds }kjk ,slk dksbZ Hkh dk;Z ugha fd;k x;k gS tks fd chek ikWfylh dh 'krksZa dk mYya?ku gksA vr% vk;ksx ls fuosnu gS fd ifjoknh dks ikWfylh ds rgr~ vuqrks"k iznku fd;k tkosA 14- fo:) i{kdkj Øekad&1 ,oa 2@ chek daiuh ds fo}ku vf/koDrk }kjk ;g rdZ fd;k x;k fd e`frdk /kkesfy;k ds }kjk fnukad&01-11-2017 dks izLrko QkeZ Hkjk x;k FkkA ml iziksty QkeZ esa dafMdk&5 esfMdy iz'ukoyh ds tokc esa chekdrkZ ds }kjk LokLF; lac/a kh iwNs x, iz'u ds lkeus mRrj No vafdr fd;k x;k Fkk ,oa LokLF; dh fLFkfr Good djds fy[kk x;k FkkA fo:) i{kdkj Øekad&1 ,oa 2@ chek daiuh us chekdrkZ dh esfMdy mipkj iphZ ds vuqlkj chekdrkZ dks izLrko&i= Hkjus ls iwoZ gh Heart Disease ¼g`n; lac/a kh chekjh½] Diabetes Mellitus Disease Fkk ,oa chekdrkZ dk V~;wej dk vkWijs'ku djk;k x;k Fkk ftls chekdrkZ ds }kjk iziksty QkeZ esa ugha crk;k x;kA chek/kkjd dh e`R;q chek ikWfylh ds ysus ds iwoZ fo|eku chekjh ds dkj.k gh gqbZ gSA chek izLrko&i= ije~ ln~Hkkouk ds fl)kar ij vuqcaf/kr fd;k tkrk gS ftldk izLrkod us ikyu ugha fd;k gS vkSj /kks[kk nsdj chek ikWfylh izkIr // 14 // fd;k gS rFkk izLrko i= esa esfMdy iz'uksa dk mfpr ,oa lgh tkudkjh ugha nh xbZ gSA chek/kkjd iwoZ ls chekj Fkh ftls izLrkod }kjk fNik;k x;k gSA fo:) i{kdkj }kjk izkIr nkok izi= dk vUos"k.k djk;k x;k Fkk rFkk izkIr vUos"k.k fjiksVZ ds vk/kkj ij nkok fujLr fd;k x;k gSA fo:) i{kdkj Øekad&1 vkSj 2 }kjk chek ds fu;e ,oa 'krksZa ds v/khu gh e`R;q nkok ns; u gksus ds dkj.k fujLr dj lsok esa dksbZ deh ugha dh xbZ gSA vr% ifjoknh dk ifjokn fujLr fd;k tkos A 15- fo:) i{kdkj Øekad&3 dh vksj ls ;g rdZ izLrqr fd;k x;k gS fd _.kh chek/kkjd ,oa fo:) i{kdkj Øekad&1 vkSj 2 ds chp gqbZ chek lafonk ds rgr~ chek nkok Hkqxrku djus dh ftEesnkjh pwafd fo:) i{kdkj Øekad&1 vkSj 2 dh gS rFkk fo:) i{kdkj Øekad&3 }kjk bl izdj.k esa fdlh Hkh izdkj dh dksbZ lsok esa fuEurk ;k deh ;k vuqfpr O;kikj&O;ogkj ifjoknh ds lkFk ugha fd;k x;k gSA ifjoknh }kjk bl izdj.k eas vuko';d :i ls bl fo:) i{kdkj Øekad&3 dks i{kdkj cuk;k x;k gS ftlds dkj.k ifjoknh dk ;g ifjokn fo:) i{kdkj Øekad&3 ds fo:) lO;; fujLr fd;s tkus ;ksX; gSA 16- ifjoknh }kjk izLrqr ,usD'kpj-C-19 rFkk fo:) i{kdkj }kjk izLrqr nLrkost izn'kZ&7 fnukad&02-01-2019 dk nkok fujLrh izi= gSA mDr izi= esa fuEu izfof"V dh xbZ gS %& "Life Insurance Contract is contract of utmost good faith. This policy was issued on the basis of the imformation disclosed in the proposal form believing the information to be true. However as per the treatment paper dated October 2017 available with us . Late Sangeeta Dhameliya was operated for tumor & suffering from Heart Disease , Diabetes Mellitus and was taking treatment for the same prior to the date of commencement of Policy .
// 15 // However , these material facts were not disclosed in the proposal form . The claim is hereby repudiated on the grounds of suppression of material facts."
17- gekjs }kjk izdj.k esa izLrqr lHkh nLrkostksa dk ifj'khyu fd;k x;kA ifjoknh }kjk izLrqr izLrko&i= dafMdk&5 esfMdy iz'uksRrj esa chekFkhZ ds }kjk lHkh dafMdkvksa ds vkxs No vafdr fd;k x;k gSA mDr izLrko i= chekFkhZ ds }kjk fnukad&01-11-2017 dks Hkjk x;k gSA fo:) i{kdkj Øekad&1 vkSj 2 }kjk izLrqr nLrkost izn'kZ OP-4 vUos"k.k fjiksVZ gSA mDr fjiksVZ dh lejh esa fy[kk gS fd chekFkhZ %& " In report mentioned as DM-III since 08 years, DMC done 02 year back and Tumor operated-2011.
Dilation and curettage (D&C) is a procedure to remove tissue from inside your uterus , Doctors perform dilation and curettage to diagnose and treat certain uterine conditions - such as heavy bleeding - or to clear the uterine lining after a miscarriage or abortion . In discharge card mentioned as DVT with shock , swelling both legs .
Deep vein thrombosis . A blood clot within a deep vein , typically in the thigh or leg . The blood clot (thrombus) can break off as an embolus and make its way to the lung . Where it can cause lung problems. Abbreviated DVT."
rFkk lq;'k gkfLiVy fnukad&10-10-2017 dk ,Mfe'ku QkeZ gS esa Qk;uy Mk;Xuksfll -DVT & Shock Thumbo in ive fy[kk gS rFkk lq;'k gkWfLiVy dh fnukad&10-10-2019 dh fMLpktZ lejh esa K/C/o-DM II 8 year rFkk Cardio Vascular Surgery dh lykg nh xbZ gS] lq;'k gkWfLiVy ds nLrkost dh // 16 // EMERGENCY ASSESSMENT SHEET esa DMC Done 2 year back rFkk Tumer Operated 2011 vafdr gS] lHkh fpfdRldh; nlrkost esa chekFkhZ ds }kjk izLrko&i= fnukad&01-11-2017 ls iwoZ ds gS ] fdarq chekFkhZ ds }kjk iwoZ dh chekjh lac/a kh dksbZ Hkh tkudkjh izLrko&i= esa ugha nh xbZ Fkh A chekFkhZ }kjk iwoZ chekjh ds lac/a k esa tkudkjh ugha nsdj chek ikWfylh izkIr dh xbZ gS] tks fd chek ds fu;e o 'krksZa dk mYya?ku gS A fo:) i{kdkj Øekad& 1 vkSj 2 us vUos"k.k fjiksVZ ,oa fpfdRldh; nLrkost ds vk/kkj ij nkok ns; uk gksus ij nkok fujLr dj lsok esa dksbZ deh ugha dh gS A 18- fo:) i{kdkj Øekad&3 _.k iznkrk cSad gS ] ftlds }kjk gkse yksu iznku fd;k x;k rFkk fizfe;e dk Hkqxrku fo:) i{kdkj Øekad&1 ,oa 2 dks fd;k x;k gS ,oa ifjoknh ds }kjk Hkh ifjokn esa fo:) i{kdkj Øekad&3 ds }kjk lsok esa deh dk dksbZ vk{ksi Hkh ugha yxk;k gS uk gh fo:) i{kdkj Øekad& 3 ls fdlh Hkh vuqrks"k dh ekax dh gS ] vr% fo:) i{kdkj Øekad&3 bl izdj.k eas vkSipkfjd i{kdkj gS A 19- mijksDr foospuk ds ifjizs{; esa ge bl fu"d"kZ ij igqaprs gSa fd e`rd chekFkhZ }kjk izLrko&i= esa iwoZ dh chekjh dk mYys[k ugha fd;k x;k Fkk tks rkfRod rF;ksa dks fNik;k tkuk ekuk tkosxkA ,slh fLFkfr esa fo:) i{kdkj Øekad& 1 ,oa 2 chek daiuh us ifjoknh ds nkos dks vLohdkj dj lsok esa dksbZ deh ugha fd;k gSA fof/k dk ;g lqLFkkfir fl)kar gS fd ifjokn dks izekf.kr // 17 // djus dk Hkkj ifjoknh ij gksrk gS] fdarq bl izdj.k esa ifjoknh vius ifjokn dks izekf.kr djus esa vlQy jgk gSA vr% ifjokn fujLr fd;s tkus ;ksX; gSA 20- vr% ifjoknh dk ifjokn fujLr fd;k tkrk gSA i{kdkj viuk&viuk okn O;; Lo;a ogu djsaxsA ¼ U;k;ewfrZ lh- ch- cktis;h ½ ¼ Jhefr :fp xks;y ½ v/;{k lnL;
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¼ xksiky panz 'khy ½ ¼ izeksn dqekj oekZ ½
lnL; lnL;
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